In addition to Workers
Compensation Insurance
for your New Jersey
business, we also offer
affordable Employee
Health Insurance plan
premiums or choose
another NJ business
insurance coverage from
the list below.
**Information received from this New Jersey Workers Compensation Insurance quote
request form sent to American Insurance Services Agency will be for our use only
and will not be sold, given to or distributed to any other parties. A quote will be based
on the workers compensation insurance plan information provided and does not guarantee
acceptance of the risk by us. The precise coverage afforded is subject to meeting
underwriting guidelines, and the terms, conditions and exclusions of the policy as
issued. By submitting this request you acknowledge that this is neither an offer to
insure nor a guarantee of insurance. Completion of this form does not entitle you
to New Jersey Workers Compensation Insurance. We are licensed in New Jersey
and will not provide quotes for other states.
"Your New Jersey Workers Compensation Insurance Agent!"
We also offer affordable New Jersey workers comp insurance premiums to businesses
in the following NJ counties and cities: Union County, Essex County, Bergen County,
Passaic County, Sussex County, Morris County, Warren County, Hunterdon County,
Somerset County, Middlesex County, Monmouth County, Mercer County, Burlington
County, Clark, Newark, Jersey City, Elizabeth, Rahway, Colonia, Iselin, Avenel,
Woodbridge, Port Reading, Carteret, Perth Amboy, Fords, South Amboy, Metuchen,
Plainfield, Dunellen, South Plainfield, Green Brook, Fanwood, North Plainfield,
Cranford, Scotch Plains, Westfield, Union, Millburn, Springfield, Mountainside, Gillette,
Warren, Watchung, Stirling, Millington, Middlesex, Martinsville, Piscataway, Edison,
New Brunswick, Highland Park, North Brunswick, Sayreville, East Brunswick,
Somerset, Milltown, South River, Bound Brook, Somerville, Bridgewater, Bayonne,
Linden, Roselle, Hoboken, Union City, Weehawken, West New York, Guttenberg,
Cliffside Park, Edgewater, North Bergen, Secaucus, Fairview, Ridgefield, Fort Lee,
Leonia, Palisades Park, Englewood Cliffs, Englewood, Bergenfield, Teaneck, Paramus,
Bogota, Ridgefield Park, Little Ferry, Hackensack, Maywood, Teterboro, South
Hackensack, Rochelle Park, Moonache, Lodi, Hasbrouck Heights, Saddle Brook,
Garfield, Elmwood Park, Woodridge, Carlstadt, East Rutherford, Lyndhurst, Rutherford,
Wallington, Passaic, Clifton, Paterson, Totowa, West Paterson, Little Falls, Great Notch,
North Caldwell, Cedar Grove, Verona, Montclair, Bloomfield, West Orange, Glen Ridge,
Belleville, Nutley, Kingsland, North Arlington, Kearney, Harrison, East Orange, East
Newark, Orange, Irvington, South Orange, Hillside, Townley, Livingston, Wayne,
Trenton, Camden, Atlantic City, Princeton, Vineland, Willingboro, and Toms River, NJ.
Business Name:    
Premises Address:
City:     State:     Zip Code:
Contact Name:
Phone #:    Ext #:
Fax:    Years in Business:
Email Address: (Required) 


Federal Employer's ID #:
Description of Operations or SIC code:


# of full-time employees:    # of part-time employees:
# of locations:    Estimated Annual Payroll: $

Select all that apply to your New Jersey business:
Operate or lease aircraft/watercraft     Work Underground
Work above 15 feet                           Require out of state travel
Use Subcontractors                            Delivery Service
Pre-employment physicals                   Offer safety incentive programs
Store, treat, dispose, or transport hazardour waste
Work on vessels, docks, or bridges over water
Other



Current Insurance Company: 
Policy #: Expiration Date: (mm/dd/yyyy)
What types of coverages do you currently have:
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Other


Other Insurance Company Used Within Past 3 Years: 
Policy #:
Losses past 3 years:
Description of losses or loss runs:


Employee       Classification Code       Yearly Payroll Estimate
      1                                         $
      2                                         $
      3                                         $
      4                                         $
      5                                         $


Principal             Name                                          Title                           Include
      1                   
      2                   
      3                   
      4                   
      5                   

Additional Information or Comments


Click on the "Submit Quote Information" button below to send your
New Jersey Workers Compensation Insurance quote request.**


New Jersey Business Information:
About Your New Jersey Business:
Recent Insurance Information:
Employee Information:
Officers / Partners / Owners Information:
New Jersey
Workers Compensation
Insurance Quote
New Jersey Workers Comp Insurance Quotes
We provide affordable Workers Compensation Insurance to businesses in New Jersey!
Do you have questions about
NJ workers comp insurance?
Copyright 2004-2008 American Insurance Services Agency - All rights reserved
NJ Business
Insurance Quotes
Workers Compensation
Insurance Quote
American Insurance
Services Agency
1129 Raritan Road
Clark, New Jersey 07066
(732) 680-4444
Fax: (732) 680-4067
"We're Your New Jersey
Workers Compensation
Insurance Agent"